Primary care management of metabolic disease made ridiculously simple 7.13.16
Chris Farnitano is totally responsible for this document Hypertension: Who to treat (Target BP goals):
150/90: age 60+ without DM or CKD (JNC8 2014)
140/90: all others (JNC8 2014)
120/90: age 50+ without DM or hx of stroke but with either known CVD, GFR<60, 10 year CVD risk >15% or age >75 (Modification based on Sprint 2015) What to treat with:
1 algorithm for all: Lisinopril/Hydrochlorothiazide 10/12.5 mg 1 tab a day
Increase to Lisinopril/HCT 20/25 1 tab a day
Increase to Lisinopril/HCT 20/25 2 tabs a day Add amlodipine 5mg 1 tab a day
Increase amlodipine 10 mg 1 tab a day Add spironolactone 25 mg a day (do not initiate if K+ Is high (>5.1), discontinue if K+ >6.0 Teaching points:
-most patients need more than one med
Most patients need a diuretic as second med
Fewer pills and doses improves compliance
Lower doses of combo pills better tolerated than full doses of single agents
Ethnic differences in responses to different classes are minimal once you are on multiple meds
Adding spironolactone to patients on 3 drugs already decreases BP by mean of 22/10
Watch for gynecomastia in men with spironolactone
Put in problem list “HTN, goal x/90” Cholesterol: Who to treat (2013 guidelines):
LDL>190 and >21 years old: use high dose statin
Known CVD:
Age <75 high dose
Age >75 mod dose
DM age 40-75 and LDL>70
If 10 year risk >/=7.5% high dose
If 10 year risk <7.5% mod dose
All others if LDL >70 and age 45-75 then calculate 10 year CVD risk using Pooled Cohort Equations
If 10 year risk >/=7.5% mod or high dose
What to treat with:
1 algorithm for all: Atorvastatin 40 mg qd (high dose) or
Atorvastatin 10-20 mg qd (moderate dose) Teaching points:
Only high dose statins are atorvastatin 40+, rosuvastatin 20+
80mg doses of all statins associated with higher rate of liver test abnormalities, no proven additional benefit over 40 mg atorvastatin
Atorvastatin is cheap and covered and potent, no need for any other drug for most patients
Rosuvastatin lowers numbers better but no proven mortality advantage, more expensive
No non-statin drugs have any proven mortality benefit. Don’t use them.
Put in problem list “hyperlipidemia, mod/high dose statin is/is not indicated”
Diabetes Type 2 Who to treat:
Goal A1c<7 in young, healthy diabetics, <8 in others What to treat with:
1 algorithm for all (type 2): Metformin 500 mg po qa dinner, increase no more often than weekly (to minimize GI upset):
Metformin 500 mg bid ac, then Metformin 850 mg bid ac, then Metformin 1000 mg bid ac Add glipizide 5 mg qam, then Increase to 5 mg bid, Increase to 10 mg bid Add long acting insulin Lantus 10 u qday, increase by 10 units at a time until fasting glucose <120
If fasting glucose <120 but A1c still >8 check post prandial glucose. Add short acting insulin lispro to 1 meal each day where highest post prandial sugars are (or biggest meal). Give lantus and lispro at same time (but different syringes) Consider* for patients who are not controlled on 100+ units of lantus and or refuse to use insulin: Adding Canagliflozin (sodium-glucose co-transport inhibitor) as combo pill with metformin: Invokamet 50/1000 bid (covered by CCHP with PA) Teaching points:
Metformin only* hypoglycemic drug with proven mortality benefit.
Do not use glyburide: higher risk of severe hypoglycemia due to renal excretion, long half life
Metformin XL does not have fewer side effects, may actually have more
Doesn’t matter when to give lantus, just same time each day
Above does not apply to Type 1 DM. These are rare in your practice. Consider referring to internal medicine for management.
Sliding scales have no role in ambulatory management of diabetes, especially in type 2s
*One large study showed a mortality benefit with one sodium-glucose co-transport inhibitor (empaglifozin, not canagliflozin) with decreased death from any cause by 32% in patients with known CVD. Causes yeast infections, UTIs, dehydration, patient falls, ketoacidosis, lowers BP 5 points.
Put in problem list “DM2, goal A1c ,7/8”
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Primary care management of metabolic disease made ridiculously simple 7.13.16
Chris Farnitano is totally responsible for this document
Hypertension:
Who to treat (Target BP goals):
150/90: age 60+ without DM or CKD (JNC8 2014)
140/90: all others (JNC8 2014)
120/90: age 50+ without DM or hx of stroke but with either known CVD, GFR<60, 10 year CVD risk >15% or age >75 (Modification based on Sprint 2015)
What to treat with:
1 algorithm for all:
Lisinopril/Hydrochlorothiazide 10/12.5 mg 1 tab a day
Increase to Lisinopril/HCT 20/25 1 tab a day
Increase to Lisinopril/HCT 20/25 2 tabs a day
Add amlodipine 5mg 1 tab a day
Increase amlodipine 10 mg 1 tab a day
Add spironolactone 25 mg a day (do not initiate if K+ Is high (>5.1), discontinue if K+ >6.0
Teaching points:
-most patients need more than one med
Most patients need a diuretic as second med
Fewer pills and doses improves compliance
Lower doses of combo pills better tolerated than full doses of single agents
Ethnic differences in responses to different classes are minimal once you are on multiple meds
Adding spironolactone to patients on 3 drugs already decreases BP by mean of 22/10
Watch for gynecomastia in men with spironolactone
Put in problem list “HTN, goal x/90”
Cholesterol:
Who to treat (2013 guidelines):
- LDL>190 and >21 years old: use high dose statin
- Known CVD:
- Age <75 high dose
- Age >75 mod dose
- DM age 40-75 and LDL>70
- If 10 year risk >/=7.5% high dose
- If 10 year risk <7.5% mod dose
- All others if LDL >70 and age 45-75 then calculate 10 year CVD risk using Pooled Cohort Equations
- If 10 year risk >/=7.5% mod or high dose
What to treat with:1 algorithm for all:
Atorvastatin 40 mg qd (high dose) or
Atorvastatin 10-20 mg qd (moderate dose)
Teaching points:
Only high dose statins are atorvastatin 40+, rosuvastatin 20+
80mg doses of all statins associated with higher rate of liver test abnormalities, no proven additional benefit over 40 mg atorvastatin
Atorvastatin is cheap and covered and potent, no need for any other drug for most patients
Rosuvastatin lowers numbers better but no proven mortality advantage, more expensive
No non-statin drugs have any proven mortality benefit. Don’t use them.
Put in problem list “hyperlipidemia, mod/high dose statin is/is not indicated”
Diabetes Type 2
Who to treat:
Goal A1c<7 in young, healthy diabetics, <8 in others
What to treat with:
1 algorithm for all (type 2):
Metformin 500 mg po qa dinner, increase no more often than weekly (to minimize GI upset):
Metformin 500 mg bid ac, then Metformin 850 mg bid ac, then Metformin 1000 mg bid ac
Add glipizide 5 mg qam, then Increase to 5 mg bid, Increase to 10 mg bid
Add long acting insulin Lantus 10 u qday, increase by 10 units at a time until fasting glucose <120
If fasting glucose <120 but A1c still >8 check post prandial glucose.
Add short acting insulin lispro to 1 meal each day where highest post prandial sugars are (or biggest meal). Give lantus and lispro at same time (but different syringes)
Consider* for patients who are not controlled on 100+ units of lantus and or refuse to use insulin:
Adding Canagliflozin (sodium-glucose co-transport inhibitor) as combo pill with metformin: Invokamet 50/1000 bid (covered by CCHP with PA)
Teaching points:
Metformin only* hypoglycemic drug with proven mortality benefit.
Do not use glyburide: higher risk of severe hypoglycemia due to renal excretion, long half life
Metformin XL does not have fewer side effects, may actually have more
Doesn’t matter when to give lantus, just same time each day
Above does not apply to Type 1 DM. These are rare in your practice. Consider referring to internal medicine for management.
Sliding scales have no role in ambulatory management of diabetes, especially in type 2s
*One large study showed a mortality benefit with one sodium-glucose co-transport inhibitor (empaglifozin, not canagliflozin) with decreased death from any cause by 32% in patients with known CVD. Causes yeast infections, UTIs, dehydration, patient falls, ketoacidosis, lowers BP 5 points.
Put in problem list “DM2, goal A1c ,7/8”